Initial Visit - Evaluation of Musculoskeletal/Nervous System Through Physical Exam

This evaluation identifies what you are going to do to help this patient. You are now going to perform an examination and/or take an X-ray.

The criteria identified under the "Indications and Limitations, etc." section of the policy must be present.

To document the presence of a spinal subluxation through physical examination, two of the four criteria listed below are required. One of the criteria must be asymmetry/misalignment or range of motion abnormality.

The four elements of the physical exam are:

• Pain/tenderness: Evaluated in terms of location, quality, and intensity.
• Asymmetry/misalignment: Identified on a sectional or segmental level.
• Range of motion/abnormality: Changes in active, passive, and accessory joint movements resulting in an increase or a decrease of sectional or segmental mobility.
• Tissue/tone changes: Changes in the characteristics of contiguous or associated soft tissues, including skin, fascia, muscle, and ligament.

This is referred to as the P. A. R. T. exam.